Exploration of attitudes and barriers to bringing patient's own

Journal of Emergency Primary Health Care (JEPHC), Vol. 6, Issue 4, 2008

ISSN 1447-4999

ORIGINAL RESEARCH Article 990313 Exploration of attitudes and barriers to bringing patient’s own medications to the Emergency Department: A survey of paramedics Esther W Chan, BPharm (Hons) MClinPharm, formerly Clinical Pharmacist, currently Honorary Research Fellow, Department of Emergency Medicine, Austin Health, Heidelberg, Victoria, Australia; PhD candidate, Department of Pharmacy Practice, Monash University, Victoria, Australia Simone E Taylor, PharmD, GCCRM, Senior Pharmacist – Emergency Medicine and Research, Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia Jennifer Marriott, BPharm, Vic.I.C., PhD, GCHE, Associate Professor, Department of Pharmacy Practice, Monash University, Parkville, Victoria, Australia Bill Barger, Ass Dip Hth Sci, MICA Cert, Manager, Clinical Standards and Audit Ambulance Victoria, Victoria, Australia

ABSTRACT Background Previous research has demonstrated that when ambulance paramedics facilitate patient‟s own medications (POM) being brought in to the Emergency Department (ED), the number of prescribing errors on the hospital admission medication chart was significantly decreased, thereby increasing admission prescribing accuracy. Aim We aimed to examine paramedics‟ attitudes to bringing POM to the ED and explore the associated barriers. Methods This was a cross-sectional survey of a convenience sample of ambulance paramedics bringing patients to the ED of a tertiary-referral metropolitan teaching hospital. The questionnaire consisted of 5 questions and took approximately 2 minutes to complete. Results The response rate for the survey was 81.9% (50/61). The study demonstrated a general agreement that bringing POM to the ED was important. Most highly rated barriers noted by respondents to bringing POM included time limitations (60%), location of patient pick up (44%), fear of losing patient‟s medications (24%) and patient‟s refusal (18%). Conclusions Overall, paramedics perceived bringing POM to ED as being important. There are identifiable barriers to paramedics bringing POM to the Emergency Department on admission. Resolution of such barriers may increase the frequency with which POM is brought to hospital, leading to a positive impact on prescribing accuracy. Keywords: allied health personnel; ambulances; emergency medical services; EMS; emergency medical technician; hospital emergency department; paramedic; survey Author(s): Esther W. Chan, Simone E. Taylor, Jennifer L. Marriott, Bill Barger.

Journal of Emergency Primary Health Care (JEPHC), Vol. 6, Issue 4, 2008

Introduction Approximately one third of patients presenting to the Austin Health Emergency Department (ED) do so via ambulance.1,2 Paramedics attend to, assess and manage patients‟ pre-hospital treatment and prepare patients for hospital admission. As part of their routine procedures, they assess patient‟s medications and routinely record certain details of the medication regimen and/or bring patients‟ medications in to hospital.1,3 This information forms part of their verbal or documented handover to the ED health-care professionals.1 Anecdotally, whether or not patient‟s own medications (POM) are physically brought in to hospital may depend on the paramedics‟ view of the importance of the information captured on the containers, the urgency of the medical condition and the site of patient pick up. Having a thorough medication history is a cornerstone of optimal therapeutic decisionmaking. It is widely recognised that most medication errors occur as patients move between the various interfaces of care, such as the community to the acute hospital. 4-9 For this reason, high priority has been placed on the importance of activities such as medication reconciliation.10-13 Whilst it is not the paramedic‟s role to obtain a complete and accurate medication history, they can potentially facilitate this process normally carried out by pharmacists and medical staff upon patients‟ admission to hospital. In practice, patients‟ own medications may be an aid to obtaining a complete and accurate medical history. Previous work has demonstrated that the presence of POM in ED reduces the incidence of prescribing errors on the admission medication chart from 25.5% of prescription orders when POM are not available to 13.1% when they are available.14,15 This survey was conducted to explore paramedics‟ attitudes of the importance of bringing POM to ED and the potential barriers to achieving this. This survey was conducted to inform the development of an intervention to encourage paramedics to bring POM to ED. The intervention was more likely to be successful if prevailing barriers to bringing POM to ED were addressed.16,17

Methods This study was a cross-sectional survey undertaken in the ED of a tertiary referral teaching hospital in metropolitan Melbourne, Australia. The ED has a mixed adult/paediatric annual patient census of approximately 60,000. The study was approved by the Austin Health Human Research Ethics Committee (HREC) and the Monash University Standing Committee on Ethics in Research (SCERH). Further approval was obtained from the Metropolitan Ambulance Service (MAS) Board of Directors and MAS Research Committee.i The study participants were paramedics, including Mobile Intensive Care Ambulance (MICA) paramedics, paramedics in training, paramedic team managers and „reserve‟ paramedics, who are allocated to vacancies in existing team rosters and do not belong to any particular team. Convenience sampling enrolled consecutive participants transporting patients to the study site during one week in October 2006 at times that the investigator (EC) was available.

i

As of 1 July 2008, Victoria’s three ambulance services (Metropolitan Ambulance Service, Rural Ambulance Victoria and Alexandra and District Ambulance Service) have been unified to form Ambulance Victoria.

Author(s): Esther W. Chan, Simone E. Taylor, Jennifer L. Marriott, Bill Barger.

Journal of Emergency Primary Health Care (JEPHC), Vol. 6, Issue 4, 2008

Paramedics were not asked to provide identified patient data. The questionnaires were personally distributed by one site investigator (EC). Completion of the questionnaire was voluntary. A participant information sheet was attached to the front of the anonymous questionnaire and paramedics‟ consent was implied by the completion of the questionnaire. The study questionnaire consisted of five questions constructed in consultation with several MAS paramedics. The brief nature of the questions was intended to minimise the potential for time restraints as a reason for refusal to participate.18,19 The questionnaire is described in Figure 1 below. Questions assessed the time spent on organising POM at the event of a non-critical case, the perceived barriers to bringing POM to hospital with the patient in the ambulance, what sources were used to compile a medication history and the perceived importance of bringing POM to ED. Responses were recorded using tick box categories, number ranking based on perceived significance, rating scales, visual analogue and open ended item format in the form of additional comments.20 Three paramedics were consulted about the length of the questionnaire, readability and interpretation as part of content validation. The questionnaire was piloted on five paramedics and minor editorial changes were made to the questions to enhance clarity. Data analysis was performed using Microsoft Excel® Figure 1. Questions used in the questionnaire to survey paramedics. Q1. Which ambulance station do you belong to? Q2. Approximately how much time do you spend on attending to patient’s medications at the event of a non-critical case? (Includes writing down a medication list, searching for medications) □ 0-5 minutes

□ 5-10 minutes

□ More than 10 minutes

Q3. What is the biggest barrier to bringing in patent’s own medications to the ED? Number boxes in order of significance of barrier (1 = biggest barrier, 5 = least important barrier) □ Time limitations □ Place of patient pick up □ Patient’s refusal □ Fear of losing medications □ Other (Please specify) Q4. How frequently do you use each of the sources of information to ascertain the medication history? (1 = always, 2= often (>60%), 3= sometimes (30-59%), 4= occasionally (5-29%), 5= rarely (